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STATE RESOURCES

Nevada Required Postings and Forms

Please print and post the following notices in a conspicuous location frequented by employees such as the break room, lunch room or time clock. If you have multiple business locations, be sure to post the notices at

each location.

D-1 Brief Description of your Rights and Benefits if you are Injured on the Job or have an Occupational Disease Poster. The title of the poster must be printed in a font no less than 20-point bold type. The required statement concerning questions and problems relating to claims must be printed in a font no less than 12-point bold type. The text appearing on the remainder of the poster must be printed in a font no less than 10-point type. The poster must be at least 11 inches by 17 inches in size. The poster must identify the name of the insurance company and where to call to report an accident or injury.

D-22 Notice to Employees. Each employer governed by the provisions of chapters 616A to 617, inclusive, of NRS who has employees who receive tips shall prominently display a poster with the language and in the format specified in Form D-22. The poster must be at least 8 1/2 inches by 11 inches in size and posted in such a manner as to be readily visible by all employees.

Please print and review the following forms with your current staff and new employees (at the time of hire):

Form D-2 Brief Description of Rights and Benefits. This form provides your injured worker with a detailed account of his/her workers’ compensation rights and benefits in Nevada. This form also provides definitions of frequently used terms and specific language on the such things as the workers’ compensation appeals process and how to file a complaint with the Division of Insurance. This form includes the Division of Insurance contact information for questions you or your injured worker may have regarding claims and workers’ compensation in general in Nevada.

The following forms need to be completed and submitted to EMPLOYERS when a work-related injury occurs:

Form C-1 Notice of Injury or Occupational Disease (Incident Report). This form should be filled out immediately after the accident by the employee’s supervisor/manager. One copy of the form must be delivered to the injured employee, and one copy of the form must be retained by the employer. The language contained in Form D-2 must be printed on the reverse side of the employee’s copy of the form, or provided to the employee as a separate document with an affirmative statement acknowledging receipt.

Form C-3 Employer’s Report Of Industrial Injury or Occupational Disease. As soon as you have been notified of a work-related injury, please fill out this form and submit it to EMPLOYERS. This form must be completed within 10 days from notice of an accident. Fatalities must be reported within 24 hours. You must use this form to notify EMPLOYERS of every work-related injury or illness suffered by an employee, regardless of severity. To avoid penalty, you must mail this form to EMPLOYERS within six working days of receipt of the C-4 form.

Form C-4 Employee’s Claim for Compensation/Report of Initial Treatment. This form should be submitted at the same time as Form C-1. A copy of the form must be provided to EMPLOYERS and to your injured worker and you must also keep a copy of this form for your records. The language contained in Form D-2 must be printed on the reverse side of the injured employee’s copy of the form or provided to the injured employee as a separate document with an affirmative statement acknowledging receipt.

Form D-8 Employer’s Wage Verification Form. This form enables us to calculate the correct compensation that may be owed to an injured employee. Please complete this form and submit it to EMPLOYERS within five days after your knowledge of any accident that has caused your employee to be disabled for more than seven scheduled work days.

First Fill Form. This form provides your employees with basic information about our Pharmacy Benefit Program, including such things as the phone number to call to locate a First Fill participating pharmacy. When your employee becomes injured, please print and complete this form and provide it to your injured employee. Your employee will need to provide this completed form along with the prescription for his/her work-related injury or illness to the pharmacist. Using this form will help enable quick authorization for your employee’s initial medication and ensure that the initial prescription is provided at no cost to the injured employee.

Accident Investigation Report. This basic accident form should be completed by the employee’s supervisor/manager as soon after the accident as possible. Please send the report to the following EMPLOYERS address as soon as it has been completed by the supervisor/manager: EMPLOYERS Claim Department, P.O. Box 32036, Lakeland, FL 33802-2036. You should keep a copy on file for your records.

Find a Pharmacy

EMPLOYERS Pharmacy Benefit Management program offers access to Point of Sale and Mail Order Pharmaceuticals. We utilize prospective, concurrent and retrospective clinical protocols, along with a drug formulary designed specifically for workers’ compensation injuries and diseases. To see your pharmacy information and providers, please select from the list below, the state in which your injury occurred.

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EMPLOYERS® and America's small business insurance specialist® are registered trademarks of Employers Insurance Company of Nevada. Insurance is offered through Employers Compensation Insurance Company, Employers Insurance Company of Nevada, Employers Preferred Insurance Company, and Employers Assurance Company. EIG Services, Inc. (in California, dba EIG Insurance Services) is an affiliated agency and adjuster. Not all insurers do business in all jurisdictions. A forward-looking statements disclaimer is an integral part of this website. *Quote availability is subject to applicable underwriting guidelines. Submitting the quote request form will not provide you with an instant quote, nor is it an application for workers' compensation insurance. By providing the information, you agree that we can share the information provided with one of our appointed insurance agents who will contact you personally within the next few business days.